NCC215673_FRO Submitted_20211013

1887
Town of ��
outhern Ines
,_(2. ! �" North Carolina
#, /?"a I The Mid South Resort
Internationally Recognized for Program Excellence
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
140 Memorial Park Court
Southern Pines, INC 28387
Telephone: [phone] Fax: [phone]
No person may initiate any land -disturbing activity greater than 30,000 sq. ft. as covered by the Town's Code of
Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed and
approved by the Town of Southern Pines and the Land Quality Section, NC. Department of Environmental Quality.
(Please type or print and, if the question is not applicable or information unavailable, place N/A in the blank.)
Part A.
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2
Project Name Braden Riley Site
Location of land -disturbing activity: Highway/Street/Address: TBD - Surrounds 480 Pee Dee Rd. Prc
Latitude 35.20184 Longitude-79.40665 County Moore City Southern Pines
3. Approximate date land -disturbing activity will commence: 11/1/21
9
n
Percent Impervious: No more than 2%
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.96
6. Amount of fee enclosed: $ 1,050
The application fee of $300.00 per acre plus $150.00 for each additional acre, or part thereof, and is
assessed without a ceiling amount. Any substantial revision to a previously approved, active plan is $50
per acre, or part thereof.
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8
9
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Braden Riley E-mail Address braden(a)rilevandwalker.com
Telephone
Cell # 919-601-1217 Fax#
Landowner(s) of Record (attach accompanied page to list additional owners):
GLP INC, LLC
Name
20 Brickdale Drive
Current Mailing Address
Pinehurst INC 28374
City
919-601-1217
Telephone
Current Street Address
State Zip City
State
Fax Number
Zip

10. Deed Book No. 3494
Page No. 78
Provide a copy of the most current deed.
Part B.
1. Person (s), Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company orfirm is a sole proprietorship
the name of the owner or manager may be listed as the financially responsible party.
Braden Riley [e-mail]
Name E-mail Address
20 Brikdale Drive
Current Mailing Address Current Street Address
Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] Fax Number
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed
name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation,
give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone Fax Number

The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath (This form must be signed by the Financially Responsible Person if an individual or his attorney -
in -fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to execute
instruments for the Financially Responsible Person). I agree to provide corrected information should there
be any change in the information provided herein.
Braden Riley
T e rint name
re
Managing Member
Title or Authority
9/2/21
Date
I, `;..�`�,s'orti ti1F�i , a Notary Public of the County of Moore
State of North Carolina, hereby certify that 1�Yc d e,---N ii'�? t ke-4 appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by
him.
Witness my hand and notarial seal, this day of �5� 20 07
O`0% lot M 000
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FOR TOWN USE ONLY;
Covered by 5/70 Provision
Notary ^�
My commission expires 1p -gyp • `.D Q-:�' -5
Yes ❑ No ❑
REVISED. December 17 2020